Bonaventure of Gresham Memory Care

The Alleged Victim (AV) has become increasingly agitated when frustrated with something or someone. To prevent altercations, the facility determined to have staff available in the common area to prevent altercations between residents. On or about April 24, 2024, AV and Witness #1 (W1) engaged in an altercation where AV grabbed W1's cup of coffee, each resident slapped each other. AV suffered a scratch to his/her right hand. The facility was short staffed this day, and were not able to keep eyes on AV. The respondent failed to ensure staff followed the service plan and ensure enough staff were available to keep residents safe. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for all mobility needs. Between the dates of February 16th through 19, 2024, AV’s air mattress came unplugged from the wall at least two (2) times. As a result, AV had a pressure ulcer on his/her coccyx that increased in size between the dates of February 16th through the 19th, 2024. On or about February 20, 2024, AV’s coccyx wound had increased in size to 2cm x 2cm x0.2 cm and was a stage 3. On or about February 24, 2024, AV’s coccyx wound was lager in size at 2.5 cm x 2.5 cm x 0.3 cm and at a stage 3. The facility failed to provide basic care and service necessary to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) had been becoming increasingly more aggressive towards staff and resident in the weeks leading up to the incident including physical assaults on other residents. On or about January 5, 2023, at breakfast time, W1 struck Alleged Victim (AV) in the back of the head two times as AV was sitting at a table for a meal. As a result of the incident, AV reported feeling fearful of W1. The facility failed to provide a safe environment putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan stated AV is a fall risk, staff are to regularly check on AV, AV requires a one-person transfer for toileting. On or about November 22, 2023, at about 10:00 pm, care staff working the swing shift left the facility and care staff working the overnight shift began working. At this point, a “shift change meeting should have taken place so that outgoing staff and incoming staff would move from room to room to discuss the current issues and care needs for residents. During the regularly scheduled rounds, overnight shift staff observed AV’s room to be empty, and AV’s bed to be made. There were no further checks on AV during the entire night shift. On or about November 23, 2023, at about 6:00am the morning shift care staff arrived, and overnight shift care staff informed morning shift staff that they had not seen AV, and they assumed AV was likely outside of the facility visiting family. At approximately 8:30am, AV was found in a locked bathroom in the common area of the facility. AV was found on the floor of the bathroom located between the wall and the toilet. As a result of the fall, AV expressed pain for multiple days. The facility failed to follow AV’s care plan regarding regular check on AV and by failing to assist AV with a one-person transfer for toileting, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. There was concern that AV may have been sexually assaulted on or about July 19, 2023. AV was found with bleeding around their genital area. It was found that this injury was due to AV shoving items like forks down their pants and briefs due to AV’s cognitive decline. However, there are no records of safety planning for interventions to address AV’s behaviors even though it had been noted as a behavior from AV’s move in at the beginning of July 2023. The facility failed to care plan around AV’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about July 4, 2023, the facility did not have AVs prescribed (comfort medication) for end-of-life comfort. As a result, AV appeared to be in distress, and no staff were available to respond Witness 2’s (W2) calls for staff assistance. A facility janitor responded and subsequently notified staff in another area of the facility. Staff believed that AV’s comfort medication order had been discontinued on or about June 28, 2023, however, following this incident, staff were told that AV’s comfort medication was located at the facility in a drawer. AV was conscious at the time, but AV couldn’t breathe, and he/she was vomiting and bleeding through his/her nose. W2 asked the facility staff if they could call EMS and the facility staff declined and stated that AV was on hospice and cannot be taken to the hospital. AV passed away on July 4, 2023, after AV experienced a great deal of discomfort for several hours. On or about July 3, 2023, staff at the facility noticed the facility had taken the comfort medication off the order list. The medication was reinstated and was put back on. None of the comfort medication orders were ever expired or canceled by hospice. On or about July 7, 2023, staff told W2 that there was comfort medication available at the time of AV’s death and showed pictures of it that were taken on June 30, 2023. The facility failed to provide a safe medication administration system for AV, leading to AV to experience a pain and discomfort, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for all his/her care needs. On or about March 21, 2023, Alleged Perpetrator 2 (AP2) grabbed AV’s right hand and caused a large skin tear when AV was resisting care from AP2. The facility offered training for AP2 on how to safely interact with resident, however, AP2 declined the training, and the training was not provided. On or about March 23, 2023, AP2 was terminated from employment after AP2 was involved in a physical altercation with another resident. AP2 was rehired for unknown reasons. On or about April 7, 2023, at approximately 8:00 AM, AV had vomited due to being sick. AP2 had attempted to physically assist AV into the shower. AV began to resist AP2, who was holding AV’s wrist and forearms. AV pulled away from AP2 and sustained a skin tear to AV’s left wrist and bruising to AV’s forearms. AP2 failed to provide a safe environment for AV, which is neglect of care and constitute abuse. The facility failed to assure AV had a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for all care needs. On or about March 21, 2023, AV and another resident were sitting on a couch in the common area of the facility AV was known to be a protective of other resident, as AV often believed that the other resident was AV’s spouse. Alleged Perpetrator 2 (AP2) approached AV and attempted to physically move AV away from the other resident by pulling AV’s hand, in an attempt to separate AV and the other resident. AV would not move and so AP2 then grabbed the other resident’s hand, which upset AV. AV began to yell at AP2. AP2 did not attempt to deescalate AV. AP2 was heard shouting by another staff member, who when they responded, they observed AV to be punching AP2. AP2 responded by punching AV in the face. AP2 failed to protect AV from physical abuse, which is neglect of care and constitutes abuse. The facility failed to assure AV was protected from physical abuse, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for all care needs. On or about March 21, 2023, AV and another resident were sitting on a couch in the common area of the facility. AV was known to be a protective of other residents, as AV often believed that the other resident was AV’s spouse. Alleged Perpetrator 2 (AP2) approached AV and attempted to physically move AV away from the other resident by pulling AV’s hand, in an attempt to separate AV and the other resident. AV would not move and so AP2 then grabbed the other resident’s hand, which upset AV. AV began to yell at AP2. AP2 did not attempt to deescalate AV. AP2 was heard shouting and said, “AV, what the (explicit word)”. AP2 failed to protect AV from verbal abuse, which is neglect of care and constitutes abuse. The facility failed to assure AV was protected from verbal abuse, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about March 1, 2023, AV exited the secure memory care unit through the stairwell exit. The exit door AV exited was not locked, the door required a key to lock and staff did not know the location of the key. The facility failed to provide a safe environment for AV, which put AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) does not like being physically touched or having clothing removed and has exhibited recent changes in behavior. On or about February 10, 2023, AV was found unclothed in Witness 6’s (W6’s) bed, with indication of sexual contact occuring. On or about February 26, 2023, AV was once again found in W6’s bed, when AV was being removed, W6 became violent and made threats towards staff. There have been at least three (3) other instances in which AV was found in W6’s room and when AV would be removed, W6 would become combative due to AV being removed from his/her room. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 5 (W5) has a known history of aggressive behaviors. On or about February 11, 2023, Alleged Victim (AV) and W5 were found in W5’s bed under the sheets with the lights off. When staff were removing AV, W5 became agitated and aggressive towards staff. This has not been the only incident in which W5 has had other residents in his/her bed. W5 has also engaged in sexual activities with a different resident. The facility failed to provide a safe environment for AV regarding W5’s known aggressive behaviors which puts AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 2 (W2) has a known history of physical aggression towards other residents and staff. On or about February 5, 2023, Alleged Victim (AV) and W2 were in the dining area when they were involved in a resident-to-resident altercation. Before staff could respond, W2 punched AV in the face claiming that AV was talking to W2’s spouse. Staff were not in the same area when they heard yelling of the altercation. The facility failed to provide a safe environment for AV, exposing AV to risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a resident of the facility. AV is diagnosed with (progressive neurodegenerative diagnosis) per his/her care plan. On or about January 21, 2023, at about 10:30 am, a driver from a transportation company arrived to the facility and informed them he/she was picking AV up. Staff escorted AV to the vehicle and boarded AV. The driver informed staff he/she was driving AV to the bank, this made staff confused, but staff did not follow up or asked the driver additional clarifying questions. Approximately 30 minutes after AV left the facility, the facility received a call from AV’s bank informing them that AV was in the bank and appeared confused. The facility had no practice/procedure in place prior to this event to safeguard against such occurrence. The facility failed to provide service to assure resident safety regarding transportation service, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) service plan indicates that AV is not incontinent of bowel, nor bladder. Multiple individuals reported that they have witnessed AV being left in a soiled diapers/undergarment. Reports indicate that the family has had to change AV’s soiled undergarments due to the facility staff not being unavailable, which resulted in skin breakdown. The facility failed to follow the service plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about November 28, 2022, AV was reported to have been refusing medications and was noted to have been experiencing an increase in agitation and aggression. AV was prescribed an antibiotic to treat a suspected urinary tract infection (UTI), and a patch to treat cognitive decline. On or about December 2, 2022, Witness 1 (W1) visited the facility and had noticed AV to be anxious and disoriented. W1 was informed that the facility had not received the orders for AV’s antibiotic and patch, W1 was told that the facility’s fax was unreliable. W1 refaxed the order to a separate fax number provided to W1. On or about December 6, 2022, W1 once again visited the facility and found that AV had an incident where AV urinated on a chair, and he/she was noted to have an increased incontinence. The facility had not yet initiated administration of AV’s antibiotics and patch. On or about December 12th and 13th, 2022, W1 had left several voice messages to the facility seeking information about the facility’s implementation of AV’s antibiotic and patch. As of December 14, 2022, the facility had not initiated administration of AV’s antibiotic and patch. The facility failed to provide a safe medication administration system for AV, putting AV in risk of harm, which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls at about one per month. On or about September 22, 2022, AV was found lying on the floor next to his/her bed. As a result of the fall, AV was sent to the hospital to be evaluated for possible head injury and was found to have sustained multiple contusions. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to have falls and to be at risk for repeated falls. Between July 1, 2022, through August 20, 2022, AV had 11 falls, as a result, AV sustained injuries in six (6) of the 11 falls which included skin tears, abrasions, bruising and bumps on his/her head. The facility made no substantive revision of AV’s care plan nor document their consideration of additional safety measure to reduce the risk of AV’s falls and the significant risk of AV sustaining injury, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 12, 2022, AV approached Witness 4 (W4) to offer W4 candy. W4 responded by punching AV in the face. AV was sent to the hospital and returned to the facility late on June 12, 2022, with a broken nose and back eye. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 5, 2022, AV was sitting in his/her wheelchair in the common area. Witness 1 (W1) walked past AV and AV hit W1. W1 then punched AV back. Following the altercation AV received a lump on his/her forehead and a laceration above his/her eye. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 5, 2022, Witness 1 (W1) was sitting in his/her wheelchair in the common area. AV walked past W1 and W1 hit AV. AV then punched W1 back. W1 has a history of prior behaviors and on occasions becoming aggressive on or about May 27th, 31st, 2022 and June 4th, 2022. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a known exit seeker. On or about May 31, 2022, AV was found outside the facility after leaving through a fire door emergency exit. AV exited through the door when staff in the memory care unit were not monitoring AV outside his/her room. AV knowns how to push the bar on the fire door to get it to unlock. AV had previously eloped through the fire door on or about May 27, 2022. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. On or about January 2022, AV sustained a large wound to his/her left arm. As a result, AV received staples to his/her arm after being seen at the hospital. The facility did not know how the wound occurred. On or about February 23, 2022, AV sustained a wound to his/her left arm in the same spot as the January 2022, left arm injury. The February 23, 2022, wound appearance was very similar to the wound sustained in January 2022. AV’s Care Plan stated he/she needs to have arm coverings or long sleeves on at all times to prevent any wounds. AV’s arms were not covered on February 23, 2022, when AV received the arm injury. AV is also care planned to received assistance with oral hygiene. AV’s teeth have been found dirty and uncared for on an ongoing basis. AV was not receiving daily oral rinse since staff could not locate AV’s rinse application cup. AV was care planned to have compression socks put on at 8:00 am and take off at 8:00pm, however, AV has not been getting his/her compression socks put on regularly. Witness 1 (W1) had witnessed AV without his/her compression socks on, on multiple occasions. The facility failed to provide service, which is a violation of resident rights, is neglect of care and constitutes abuse.

Based on interview and record review, conducted during an investigation on 03/04/26, the facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated, which is a violation of Oregon Administrative Rules.

The facility failed to determine and document actions or intervention needed for a resident experiencing a short term change of condition and ensure a resident monitoring and reporting system is implemented 24-hours a day in accordance with OAR 411-054-0040(1 & 2).

The facility failed to complete service plans quarterly after the resident moved into the facility in accordance with OAR 411-054-0036(4)(a).

The facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse in accordance with OAR 411-054-0028(2)(b).

The facility failed to develop and implement written policies and procedures that promote high quality services, health, and safety for residents in accordance with OAR 411-054-0025(7).

The facility failed to make records available to the Department upon request in accordance with OAR 411-054-0105(1)(a).

Based on interview and record review, conducted during an investigation on 03/04/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 03/04/26, the facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 03/04/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 03/04/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 03/04/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

The facility failed to make records available to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to make records available to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about 8/10/2023, Alleged Perpetrator 2 (AP2) and AV got into an altercation where AP2 grabbed AV's left wrist and elbow around 6:00PM-6:15PM. AV was yelling out and screaming. AV was upset. AP2 was sent home due to the noted behaviors at approximately 6:30PM-6:45PM. AP2 has training that all staff receive. The training includes treatment of residents and types of abuse of residents. AP2 failed to protect AV from physical abuse, which is neglect of care and constitutes abuse. The facility failed to assure that AV was protected from physical abuse, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about August 10, 2023, Alleged Perpetrator 2 (AP2) and AV got into an altercation around 8:30PM-9:00PM, where AP2 was attempting to make AV stand up when AV did not want to stand. AP2 has training that all staff received. The training includes treatment of residents and types of abuse of residents. AP 2 failed to protect AV from verbal abuse, which is neglect of care and constitutes abuse. The facility failed to protect AV from verbal abuse, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about August 10, 2023, Alleged Perpetrator 2 (AP2) and AV got into an altercation around 8:30PM-9:00PM, where AP2 was attempting to make AV stand up when AV did not want to stand. AP2 was witnessed striking at AV on the arms in an attempt to get AV to stand up. AP2 was trained on how to provide service to residents, the training includes treatment of residents and types of abuse of residents. AP 2 failed to protect AV from physical abuse, which is neglect of care and constitutes abuse. The facility failed to protect AV from physical abuse, which is a violation of Oregon Administrative Rules.

The facility failed to make records available to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to make records available to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide a safe medication administration system for the Alleged Victim. An investigation determined this to be a licensing violation.

The facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse and to require all facility employees to immediately report abuse and suspected abuse. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 13, 2022, it was reported that Alleged Perpetrator 2 (AP2) was aggressive and rude to AV on multiple occasions, angrily yelling at AV while getting very close to AV’s face, when AV asked AP2 a question multiple time. AP2 doesn’t usually use a loud voice but gets frustrated when AV asks repeated questions and escalates to yelling at AV. AP2 failed to protect AV from verbal abuse, which is neglect of care and constitutes abuse. The facility failed to assure AV was protected from verbal abuse, which is a violation of Oregon Administrative Rules.

he facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.

Facility failure to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing, which is a violation of Oregon Administrative Rules.

The facility failed to provide a daily program of social and recreational activities, which is a violation of Oregon Administrative Rules.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, which is a violation of Oregon Administrative Rules.